Long Hand Charting for Iv Insertion and Removal, Trach Care and Suctioning with Dressing Change

Good Essays
Pt requires 20 gauge IV for _______. 20 gauge catheter inserted to the right anterior forearm, first attempt. Flushed with 10 cc normal saline. Stat lock in place, covered with transparent dressing. Pt tolerated well with no complaints of pain or irritation upon flushing, no visible swelling or bruising. Sharps placed in approved container, patient’s bed lowered as far as possible and assisted to comfortable position. Reassessed in 5 minutes for bleeding , none noted.

Pt requires IV discontinuation d/t: pain / infiltration / expiration of indwelling time frame. Discontinue 22 gauge IV catheter from L hand. Cannula intact. Pressure held for 3 minutes, assess for continue blood loss, none noted. 2 x 2 gauze dressing with paper tape covering IV site. Pt tolerated well, no complaints of pain or swelling. Reassessed in 5 minutes for bleeding , none noted

Pt requires tracheostomy suctioning d/t increased respiratory rate of 26, crackles bilaterally in upper lobes, use of accessory muscles and decreased pulse ox of 90%. Pt placed in semi fowlers position, raised to working height, side rail down. Pt draped with towel. Wall suction at 120 mmHg, Prepackaged suction catheter opened, sterile gloves donned, tubing and catheter connected and tested with sterile saline for proper suction. Pt hyperoxygenated per policy, catheter lubricated with saline and inserted to tracheostomy without suction, advanced down without resistance, suctioned while removing catheter. Thick yellow secretions removed on first attempt, provided patient time to hyperoxygenate, reinserted catheter scant amount of yellow secretions removed on second attempt. Pt respiratory status assessed, lungs clear bilaterally pulse ox increased to 94%, respirations 20/min. Moist toothette to clean oral cavity, side rails raised, bed lowered to lowest position, pt states “it’s easier to breathe now”.

Pt requires tracheostomy scheduled routine dressing change. Pt placed in semi fowlers position, bed raised to

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